SCOPE OF APPOINTMENT - Confirmation Form

Before meeting with a Medicare Beneficiary (or their authorized representive). Medicare requires that Licensed Sales Representatives use this form to ensure your appointment focuses only on the type of plan and products you are interested in. A seperate form should be used for each Medicare beneficiary. Please check what you want to discuss with the Licensed Sales Representative. Tina Louise Lasser aka The Medicare Lady does not work directly for the federal governement. Check ALL that apply.

Medicare Advantage (Part C)

Medicare Supplement (Medigap)

Stand-alone Medicare Prescription Drug Plan (Part D)

Stand-alone Dental/Vision/Hearing (not Medicare products- available for all ages)

*

By Choosing YES on this form, You agree to meet with a licnensed sales representative (Tina Louise Lasser) to discuss the products checked above. Tina is contracted by Medicare Plans and may be paid based on your enrollment in a plan. I understand chosing Yes on this form does not affect my current of future enrollment in a Medicare plan, enroll me in a Medicare plan or obligate me to enroll in a Medicare plan. ALL INFORMATION ON THIS FORM IS CONFIDENTIAL.

Yes

No

Beneficiary Name *

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date

MM

DD

YYYY